Dysphoria

Some shifts the emergency department offers a glimpse into a distorted reality.

It was well past midnight and I was starting to feel my 65 years, so I was somewhat relieved to pick up the chart and see “vomiting” as the chief complaint. “18 y/o female.” Hmm, I thought, either she has a bug or she’s gotten into her parents liquor cabinet with some of her friends. I’m betting this will be quick and easy. Boy was I wrong.

She was 18 years old. Thin, pale, and had either lost a lot of weight or was wearing the faddish clothing of a much heavier person.

“How long have you been vomiting?” I started with my usual line of questioning after a brief professional introduction.

“Years, it’s been over two years,” the father blurted out. He was standing in the corner as if he had been banished by the other two. In fact, I hadn’t really noticed he was there until he spoke. He was wearing exercise clothing that appeared to be tastefully and carefully coordinated with an expensive pair of cross trainers and a Rolex. He had a perfect tan and, despite the hour, his hair was appropriately tousled.

“Let Evelyn speak for herself,” her mother chided. “She has a mind of her own.” Now it was time for me to take in the third person in the room. With straw blonde hair, she was the picture of an aging beauty. Not old by any means. Just starting to show her age…and she was fighting the good fight. What obviously had been a figure that once drew stares was now encircling her waist and hips. The laugh and experience lines on her face were barely concealed by botox.

“I’m fine,” the teen said with a note of exasperation. “I’m just losing a little weight, that’s all.”

“It’s not ‘just a little weight, sweetheart,” the father said softening to a plea. “You’ve lost over 30 pounds.”

“I think she’s sick,” mom interjected. “Can you test her for something?” she asked, looking to me. It was obvious she wanted me to settle a family argument that had been going on for a while.

“You are sick,” the father said desperately. “But it’s not a bacteria. Something has infected your mind. Somehow you’ve gotten this idea in your head that you’re fat.”

“Daddy!” the teen responded with a flash in her eyes. “You make it sound like I’m crazy. I’m NOT crazy! I just want my body to be consistent with how I feel inside.”

“How do you feel inside?” I asked finally jumping into the conversation.

“I don’t know,” she said with a shrug. “I just know that the body I was given is not ME.”

“Really?” I said softly, trying to draw the patient into a one on one. I stepped closer and placed my hand ever so lightly on her frail, bony fingers. I could feel that I was on pretty thin ice and the last thing I wanted was to have my touch misconstrued. But I felt establishing a human bond, of even the smallest measure, was critical to getting past the three-way name-and-blame game that I saw happening in the room.

“I,” she said with emphasis, “am sensual, romantic, mysterious, and, you know…unique.”

“I’m sure you are…that…and much, much more,” I said with a nod. I saw the first flash of a slight smile from her. “But what does that have to do with your body? You…are all of those things, no matter what you see in the mirror.”

“I think it is something genetic, Jason,” mom said, breaking the connection. “I never said she had a bacteria. Can you test her genes?”

Now the spell was completely broken because all I could think of was a prank my grandson played on me by claiming that diarrhea was inherited. I assured him that it wasn’t. But he insisted by loudly exclaiming he knew diarrhea was inherited because it “was in my jeans.”

“I’m sorry,” I deadpanned to the mother. “We don’t do genetic testing in the ER.” For starters, I wasn’t sure what she wanted me to do genetic testing for…obesity, maybe?

“Now you see what I’m talking about, doc,” dad said. “Evelyn says that she is a ‘thin person trapped inside of a fat person’s body’. So she’s taking diet pills and making herself vomit. If I’d let her, I think she would have liposuction.”

“It’s my right to see myself in any way I want. I am who I am. My teacher is always encouraging me to be who I am on the inside. Other kids are on pills to change them. Some even are planning surgery.”

“I agree, baby, you are who you are on the inside. But you’re letting that destroy who you are on the outside,” her father implored.

“You told me how you see yourself on the inside,” I interjected. “But how do you see yourself on the outside?”

“Well, she was a little heavy,” she said slightly pursing her puffy lips as if she was weighing her in her mind. “But now she’s a little too thin.”

I looked over at the scribe in the corner who had been clicking away wildly on the computer throughout the interview. She saw the look in my eyes. Deep sigh. I was rolling my wedding band nervously. I had three people who saw reality in three very different ways. I empathized with the father and his concern for his daughter. But I couldn’t help feel that this ‘perfect’ man expected the same from those around him. His formerly ‘perfect’ wife had infected their daughter with an insatiable desire for the same unattainable picture. And now, the three of them were stuck with a real reality that no one liked. And they thought I could fix the situation? Tonight? Here in the ER?

Good luck with that one, I thought.

“How much DID you weigh?” I asked, finally breaking the silence. “Before, that is. Before you started losing weight.”

“A hundred and fifteen pounds,” dad said without hesitation. Everyone nodded in agreement. It was the first agreement of all three people since my introduction.

That’s a good starting point, I thought. It’s not much, but it’s something. “Are you willing to talk to another doctor that specializes in this kind of thing,” I said trying to indicate a plan. “She’ll start by looking at what weight is normal for…” I saw the girl wince. “I’m sorry, I don’t mean to suggest that you are not normal. That was a bad choice of words. She’ll look at the range of weights for other teenagers your height and age. And she might help you get comfortable with who you are on the outside so that inside and outside become the same. You know that you are quite a remarkable person.”

Everyone in the room seemed to smile cautiously. “If she thinks that a medical work up, you know blood tests and other things, are indicated, she will order them at that time,” I added as I made my way to the door.

FOUNDER / EXECUTIVE EDITOR
Dr. Plaster has been an emergency physician for more than thirty years, working exclusively night shifts for the past twenty years in emergency departments across the country. During that period he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly, founder of Plaster Publishing, and is currently running for the House of Representatives in Maryland's 3rd district.

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